Impact of tooth brushing on oral bacteriota and health care-associated infections among ventilated COVID-19 patients: an intervention study

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Abstract

Background

Up to 48% of ventilated coronavirus disease 2019 (COVID-19) patients develop ventilator-associated pneumonia (VAP) during hospitalization in an ICU. Dysbiotic oral microbiota can colonize the lower respiratory tract and lead to VAP. It is recommended to introduce oral care strategies in the ICU to prevent VAP. In this study, we observed the impact of an oral hygienic protocol with tooth brushing on cultivable oral bacteriota, the incidence of HAI and patient safety among mechanically ventilated COVID-19 patients in an ICU setting.

Methods

In this prospective cohort study, we recruited 56 adult COVID-19 patients who qualified for mechanical ventilation. Patients were divided into 2 groups depending on the oral care procedure: standard and extended oral procedures with tooth brushing. Oral bacteriota samples were taken first within 36 h and after 7 days of intubation. Microorganisms were identified by MALDI/TOF mass spectrometry. bacterial health care-associated infection (HAI) cases were retrospectively analyzed by etiology. A PFGE study was performed for Klebsiella pneumoniae to check for clonal spreading of strains from oral bacteriota samples and HAI cases.

Results

We observed significant dysbiosis and a decrease in cultivable oral bacteriota diversity, with a high frequency of potentially pathogenic species, including Acinetobacter baumannii and K. pneumoniae. The HAI incidence rate was high (55.2/1000 patient-days), most commonly of K. pneumoniae and A. baumannii etiologies, which correlated with the presence of A. baumannii and K. pneumoniae in the oral samples. Strains isolated from VAP cases were the same as oral isolates in 8 cases. The procedure with tooth brushing led to less frequent identification of A. baumannii in oral samples (55.6% vs. 5.3%, p = 0.001); however, it did not decrease the incidence of HAIs.

Conclusions

Dysbiotic oral bacteriota is an important source of respiratory pathogens. The introduction of tooth brushing in oral hygiene protocols in an ICU setting was effective in decreasing the extent of oral bacteriota dysbiosis; however, it did not reduce the risk of HAIs or mortality.

Trial registration: 1072.6120.333.2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-023-01218-y.

Related collections

Most cited references 39

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International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT).

Antoni Torres, Michael Niederman, Jean Chastre … (2017)

The most recent European guidelines and task force reports on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) were published almost 10 years ago. Since then, further randomised clinical trials of HAP and VAP have been conducted and new information has become available. Studies of epidemiology, diagnosis, empiric treatment, response to treatment, new antibiotics or new forms of antibiotic administration and disease prevention have changed old paradigms. In addition, important differences between approaches in Europe and the USA have become apparent.The European Respiratory Society launched a project to develop new international guidelines for HAP and VAP. Other European societies, including the European Society of Intensive Care Medicine and the European Society of Clinical Microbiology and Infectious Diseases, were invited to participate and appointed their representatives. The Latin American Thoracic Association was also invited.A total of 15 experts and two methodologists made up the panel. Three experts from the USA were also invited (Michael S. Niederman, Marin Kollef and Richard Wunderink).Applying the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology, the panel selected seven PICO (population-intervention-comparison-outcome) questions that generated a series of recommendations for HAP/VAP diagnosis, treatment and prevention.

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Ventilator-associated pneumonia in adults: a narrative review

Laurent Papazian, Michael Klompas, Charles-Edouard Luyt (2020)

Ventilator-associated pneumonia (VAP) is one of the most frequent ICU-acquired infections. Reported incidences vary widely from 5 to 40% depending on the setting and diagnostic criteria. VAP is associated with prolonged duration of mechanical ventilation and ICU stay. The estimated attributable mortality of VAP is around 10%, with higher mortality rates in surgical ICU patients and in patients with mid-range severity scores at admission. Microbiological confirmation of infection is strongly encouraged. Which sampling method to use is still a matter of controversy. Emerging microbiological tools will likely modify our routine approach to diagnosing and treating VAP in the next future. Prevention of VAP is based on minimizing the exposure to mechanical ventilation and encouraging early liberation. Bundles that combine multiple prevention strategies may improve outcomes, but large randomized trials are needed to confirm this. Treatment should be limited to 7 days in the vast majority of the cases. Patients should be reassessed daily to confirm ongoing suspicion of disease, antibiotics should be narrowed as soon as antibiotic susceptibility results are available, and clinicians should consider stopping antibiotics if cultures are negative.

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Is Open Access

Oral Microbiome and SARS-CoV-2: Beware of Lung Co-infection

Lirong Bao, Cheng. Zhang, Jiajia Dong … (2020)

The new coronavirus SARS-CoV-2, the cause of COVID-19, has become a public health emergency of global concern. Like the SARS and influenza pandemics, there have been a large number of cases coinfected with other viruses, fungi, and bacteria, some of which originate from the oral cavity. Capnocytophaga, Veillonella, and other oral opportunistic pathogens were found in the BALF of the COVID-19 patients by mNGS. Risk factors such as poor oral hygiene, cough, increased inhalation under normal or abnormal conditions, and mechanical ventilation provide a pathway for oral microorganisms to enter the lower respiratory tract and thus cause respiratory disease. Lung hypoxia, typical symptoms of COVID-19, would favor the growth of anaerobes and facultative anaerobes originating from the oral microbiota. SARS-CoV-2 may aggravate lung disease by interacting with the lung or oral microbiota via mechanisms involving changes in cytokines, T cell responses, and the effects of host conditions such as aging and the oral microbiome changes due to systemic diseases. Because the oral microbiome is closely associated with SARS-CoV-2 co-infections in the lungs, effective oral health care measures are necessary to reduce these infections, especially in severe COVID-19 patients. We hope this review will draw attention from both the scientific and clinical communities on the role of the oral microbiome in the current global pandemic.

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Author and article information

Contributors

Kania Michal: mich.kania@doctoral.uj.edu.pl

Journal

Journal ID (nlm-ta): Antimicrob Resist Infect Control

Journal ID (iso-abbrev): Antimicrob Resist Infect Control

Title: Antimicrobial Resistance and Infection Control

Publisher: BioMed Central (London )

ISSN (Electronic): 2047-2994

Publication date (Electronic): 8 March 2023

Publication date PMC-release: 8 March 2023

Publication date Collection: 2023

Volume: 12

Electronic Location Identifier: 17

Affiliations

[1 ]GRID grid.5522.0, ISNI 0000 0001 2162 9631, Institute of Dentistry, Faculty of Medicine, , Jagiellonian University Medical College, ; Ul. Montelupich 4, 31-155 Kraków, Poland

[2 ]GRID grid.412700.0, ISNI 0000 0001 1216 0093, Department of Endocrinology, , University Hospital, ; Ul. Jakubowskiego 2, 30-688 Kraków, Poland

[3 ]GRID grid.5522.0, ISNI 0000 0001 2162 9631, Doctoral School of Medicine and Health Sciences, , Jagiellonian University Medical College, ; Ul. św. Anny 12, 31-008 Kraków, Poland

[4 ]GRID grid.5522.0, ISNI 0000 0001 2162 9631, Chair of Metabolic Diseases, Faculty of Medicine, , Jagiellonian University Medical College, ; Ul. Jakubowskiego 2, 30-688, Kraków, Poland

[5 ]GRID grid.412700.0, ISNI 0000 0001 1216 0093, Microbiology Unit, , University Hospital, ; Ul. Jakubowskiego 2, 30-688 Kraków, Poland

[6 ]GRID grid.5522.0, ISNI 0000 0001 2162 9631, Chair of Angiology, Faculty of Medicine, , Jagiellonian University Medical College, ; Ul. Jakubowskiego 2, 30-688, Kraków, Poland

[7 ]GRID grid.5522.0, ISNI 0000 0001 2162 9631, Chair of Microbiology, Faculty of Medicine, , Jagiellonian University Medical College, ; Czysta 18, 31-121 Kraków, Poland

[8 ]GRID grid.412700.0, ISNI 0000 0001 1216 0093, Center for Innovative Therapy, Clinical Research Coordination Center, , University Hospital, ; Ul. Jakubowskiego 2, 30-688 Kraków, Poland

Article

Publisher ID: 1218

DOI: 10.1186/s13756-023-01218-y

PMC ID: 9992909

PubMed ID: 36890608

SO-VID: 501dddc1-58d7-4c43-bf25-72221a92e514

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 23 October 2022

Date accepted : 15 February 2023

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100005632, Narodowe Centrum Badań i Rozwoju;

Award ID: SZPITALE-JEDNOIMIENNE/18/2020

Award Recipient : Gregorczyk-Maga Iwona Pałka Anna Fiema Mateusz Kania Michal Kujawska Anna Maga Paweł Jachowicz-Matczak Estera Romaniszyn Dorota Chmielarczyk Agnieszka Żółtowska Barbara Wójkowska-Mach Jadwiga